Late referral to maintenance dialysis: detrimental consequences

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Abstract
Thirty per cent of patients who started maintenance haemodialysis at our institution between January 1989 and December 1991 had been referred at a very late stage of their renal disease. To assess the causes and consequences of such late referral we retrospectively compared clinical and laboratory features of 65 patients who had been referred less than 1 month prior to first dialysis (late referral, or LR group) and of 153 patients who had been previously followed-up by us for more than 6 months (early referral, or ER group). Age, sex ratio, and socioeconomic status were similar in the two groups. In the LR group, 38 patients had never been referred to a nephrology unit, whereas 27 had discontinued nephrological surveillance. Fluid overload, severe hypertension, and/or pulmonary oedema was present in 57% of LR versus 15% of ER patients (PPP<0.0001), resulting in an excess cost of 0.2 million French francs per LR patient. We conclude that patients referred at a late stage of renal failure without previous nephrological follow-up had strikingly more severe uraemic disorders, together with poorer blood pressure control and clinical condition, than patients receiving adequate nephrological care, and needed prolonged hospitalization to recover. Such potentially avoidable deleterious effects strongly suggest the need for earlier and closer co-operation between general practitioners and nephrologists.

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